Improving health for dual-eligible people

Humana engages with individuals dually eligible for Medicare and Medicaid programs through Medicare Advantage Special Needs Plans (SNPs) as well as through innovative federal/state demonstration programs. Humana is participating in joint Centers for Medicare & Medicaid Services (CMS)/state Medicaid department demonstration projects in Illinois and Virginia to address the quality and financial integration issues around the care of people who are dually eligible for Medicare and Medicaid. “Dual eligible” individuals, as these seniors and younger people with disabilities are called, typically are some of the most vulnerable people in the healthcare system.

As a group, dual eligible individuals account for a disproportionate share of spending in both programs. People who qualify for full dual benefits are estimated to make up 13 percent of the combined population of Medicare enrollees and aged, blind or disabled Medicaid enrollees, but they account for 34 percent of those programs’ total spending on those enrollees, according to a 2013 report by the Congressional Budget Office.

Humana’s approach

Our goal is to improve population health outcomes and help states and the federal government control costs for the vulnerable dual eligible population. The first step is to make using the healthcare system easier. Medicare and Medicaid are two different programs that cover different things, operate under different rules and were never designed to work together. Under the demonstration program, Humana works to integrate the two programs to provide as seamless a level of coverage to our members as possible, giving them one card, one point of contact, one set of benefits, and one care treatment plan. We also take real responsibility for dual eligible members by managing and integrating their care.

Here’s how we accomplish those goals:

  • Connect with individuals about their health: Humana’s care managers work to make phone contact with each person who is dually eligible in a variety of ways, including telephone, mail and, in some cases, in person after receiving enrollment information. The purpose is to evaluate each person, identify his or her individual needs, and then convert what is learned into ways to help. The goal always is to keep members healthy as they can be—stable, out of the hospital and at home.
  • An emphasis on primary care: Keeping people healthy starts with primary care doctors and their teams taking responsibility for patients, coordinating their care, and collaborating with other providers across the healthcare spectrum.
  • Identify members who would benefit from special care programs: Humana also makes use of predictive modeling programs, member self-disclosures, and care coordinator evaluations  to find members who may benefit from special care programs. Then a multi-disciplinary team of care workers, nurses, social workers, and physicians engages with them and works to help them overcome barriers to health that often are social and logistical, as well as medical. The care teams’ activities include a range of possibilities, including assisting members with understanding and following their physician’s recommended treatment plan, helping manage transitions from hospital to home, and ensuring the members have the food, prescription drugs and medical equipment that they may need.
  • Support during transitions: Humana’s 30-day Transitions program helps members go from hospital, or nursing home, to home. Often patients are on their own once they leave a treatment facility. Humana assists them to get what they need, whether it's transportation, a prescription filled, necessary equipment, or meals delivered.

Implementation of the dual-eligible demonstrations began in 2014, and the feedback so far has been promising. Through the patient-care worker meetings that occur in order to create individualized plans, relationships are formed and needs are seen and addressed.

To learn about Humana’s policy on dual-eligible people, check out this page.